For me, really, everything starts with understanding the patient rather than just understanding the products. When we do training, we focus a lot on the products, but we really have to go back to the patient experience and the patient needs. And people sometimes ask, “so what is your favorite barrier cream,” when I'm presenting about MASD, for example, or, “what kind of dressing do you recommend?” My answer is usually that I don't have a favorite product. (There are instead), let's say, principles that are my favorite. And the first question I ask is, “what is threatening this patient, this person's skin?” Is it the excessive moisture? Is it dryness? Is it the repeated removal of the adhesive? Is there any significant edema? Is there any friction from movement?  

And if you don't understand the underlying mechanism, choosing the product becomes really like guessing or guesswork. And then I'll also look at the patient's skin resilience. A healthy young trauma patient, for example, and a frail 90-year-old with diabetes and chronic venous disease, of course, they have a completely different skin biology. So that means they will require a different approach. And once you understand the cause, you try to remove the cause whenever possible before adding any protective intervention. So go to the patient first and then consider the product needs. And other questions. Can I improve the exudate management? Can I reduce the dressing change? Can I minimize the adhesive exposure, etc.? And only then I think about the cleansing, about moisturization, about any barrier products and dressing. 

So, as I do in my lectures, I really strongly advocate for gentle pH-balanced cleansing because we need to maintain the acid mantle of the skin. And I think that clinicians, they don't always realize how incredibly important that acidity of the skin's mantle definitely is. So especially when we have to cleanse the patient's skin repeatedly over days, weeks, and months. And then secondly, moisturization. Moisturization is often underestimated. We spend a lot of time thinking about moisture on the wound, but much less time thinking about hydration of the surrounding skin. Healthy, hydrated skin is mechanically—and remember I mentioned about friction and mechanical force and shearing. So, hydrated skin is mechanically stronger and definitely more resilient. 

We have to realize that in the third step, and that's talking about the barrier products, they certainly do have an important role to play, but I don't think they should become routine without any clear indication. So, our selection of those barrier products, they should be based again on the patient's exposure to the moisture, compatibility with any dressing that you would apply, and also the expected frequency of the application. And then finally, dressing selection becomes really part of your skin protection. So an ideal dressing does not only manage the exudate, it also should protect the surrounding skin, minimize the trauma during the removal, and also conform well to the body and allow the skin to recover. And there is a lot of research on this as well.  

That's my last point. Perhaps the most important thing for me, at least, that I would like to emphasize is that skin protection is not just a one-time decision. Every dressing change is another opportunity to assess and reassess the skin and also to adjust the strategies that I just explained.